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SFM2 > Lower Back and Hip Pathology > Flashcards

Lower Back and Hip Pathology Flashcards

1
Q

lumbar disk herniation

defn and causes

A

wear and tear –> minor tears in annulus fibrosis –> major tears in annulus fibrosis –> protrusion of nucleus pulposa –> pain, possible radiculopathy and myelopathy d/t direct compression or inflammation

typically posteriolateral d/t typical pattern of anterior compression from frequent flexion e.g. bending and sitting

also posterior longitudinal ligament

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2
Q

lumbar disk herniation

radiculopathy clinical presentation

A

nerve root exits below level of lumbar disk (as opposed to cervical exiting above)

posterolateral herniation usually spares nerve root at that level and instead the next one below that (so L4 herniation would affect L5 nerve, which is below L5)

far lateral does not spare (L4 herniation would affect L4 root)

most common herniations are L4/L5 and L5/S1 –> most common radiculopathies at L5 and S1. both cause sciatica. sensory and/or motor involvement.

significant compression of thecal sac may also cause cauda syndrome – bowel and bladder incontinence, loss of motor and sensory in legs

else motor and/or sensory following any specific myotomal distribution

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3
Q

lumbar dis herniation

clinical presentation and PE findings

A

local low back pain, midline and/or paraspinals

worse with low back movement

bilateral paraspinal spasm

loss of lumbar lordosis

limited ROM d/t pain

radiculopathy - usually sciatica, foot drop also common –> abnormal gait

possible cauda equina syndrome – bowel and bladder incontinence, loss of motor and sensory to LE

special testing: straight leg raise for sciatica

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4
Q

lumbar disk herniation

tx and prognosis

A

pain relief +/- muscle relaxants +/- epidural corticosteriods

PT, traction, heat/ice

pain usually resolves in 6 weeks w/ conservative tx

radiculopathy and myelopathy have more complications, surgery may be needed

surgery indicated in cauda equina syndrome

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5
Q
A

L4/L5 lumbar disk herniation

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6
Q

sacroiliac joint dysfunction

defn and causes

A

changes in SI alignment d/t changes in ligament integrity

sitting and trauma –> short and tight SI ligaments

trauma and pregnancy –> lax

muscular imbalance –> SI stress

aging –> degeneration, uneven, possible fusion

ligament changes can result in inflammation, but not the same as sacroiliitis, which is inflammation not d/t ligment changes, such as in ankylosing spondylitis

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7
Q

lumbar muscle strain

A

muscle injury d/t exertion, overstretching, or overuse

most common cause of back pain, usually starts in lower back and migrates to hip and buttock

improper lifting technique is common cause of acute strain, esp in normally sedentary individuals or with particularly heavy object

most resolve quickly and spontaneously

paraspinal spasm –> loss of lumbar lordosis, limited ROM d/t pain and stiffness

chronic strain d/t muscle “bracing” (overuse of certain muscles to make up for others) d/t instability, ddd, herniation, stress and anxiety disorders — ie. concurrent muscle strain is common in other neck and back conditions

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8
Q

lumbar dermatomes

A

L2-3 anterior/mid-thigh

L4 knee and medial malleolus

L5 web b/w 1st and 2nd toe

S1 lateral malleolus

L5 and S1 are also associated with sciatica, but that’s not technically a dermatome

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9
Q

lumbar myotomes

A

L2-4 knee extension and hip aDduction

L5 ankle dorsiflexion (extension) and big toe extension

S1 ankle plantarflexion, knee flexion, hip extension (“tuck”)

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10
Q

lumbar radiculopathy

clinical presentation and PE findings

A

painful or antalgic gait

possible reactive paraspinal spasm w/ associated pain, stiffness, tenderness to palpation

limited ROM d/t pain/reproduction of sx

no tenderness to palpation in affected extremities

dermatomal paresthesia and/or myotomal weakness w/ possible loss of reflexes

special testing: straight leg raise, EMG

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11
Q

lumbar radiculopathy

tx and prognosis

A

NSAIDs for inflammatory pain + neuropathic pain meds +/- epidural corticosteroids

acute: laying supine for 2 days to reduce compression
chronic: PT, ergonomics, lifting techniques, weight loss if applicable

avoid lifting, stooping, bending, prolonged standing or sitting while active sx

lumbar traction (temporary)

if severe, surgical removal of underlying cause e.g. herniation or osteophytes

most sx resolve spontaneously w/ conservative tx

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12
Q

lumbar spinal stenosis

defn and causes

A

narrowing of central spinal canal

disk herniation, large osteophyte, hematoma s/p trauma or spinal procedure, tumor, foreign body

cervical spine: spinal cord compression

lumbar: cauda equina
anywhere: radiculopathy

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13
Q

spinal stenosis

clinical presentation and PE findings

A

usually progression of disk herniation, ddd, or spondylolythesis

multilevel bilateral sensory and motor – high suscpicion if this is present

lumbar: below level of lumbar, common complication is cauda equina syndrome

often stooped posture as this opens up canal and relieves sx

reduced muscle tone and hypo or areflexia

cervical: hyperreflexia of lower extremities and increased tone. upper motor neuron = uninhibited descending pathway; spurling’s sign: pain radiating down arm with neck extension

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14
Q
A

spinal stenosis + L4/L5 herniated disk

lumbar

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15
Q

spinal stenosis

tx and prognosis

A

pain management + oral corticosteroids for pain and weakness

epidural steroids not usually helpful - even small volume injections into already-tight space worsens sx

decompression surgery for osteophyte, disk, etc. removal may be needed; cervical and thoracic needs immediate surgical decompression d/t compression of spinal cord

mild stenosis from herniated disk usually resolves spontaneously

ddd, osteophytes, ligamentum flavum thickening, congenital short pedicles –> likely progressive

tx will typically prevent progression of but not reverse neurological deficits

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16
Q

spinal compression frx

A

collapsing or crushing bone d/t injury and/or weak structure

fall landing on butt or feet

osteoporosis

lower thoracic and thoracic-lumbar most common

cracks may not always be obvious on xray, look for height of vertebral body

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17
Q

spondylolysis

A

pars interarticularis frx

usually L5/S1

neck of “scotty dog” on xray

trauma w/ hyperextension, commonly gymnasts

5% overall lifetime incidence

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18
Q
A

spondylolysis = pars interarticularis frx

19
Q

spondylolisthesis

A

vertebral slippage

20
Q

spondylosis

A

any condition of the spine

21
Q

avascular necrosis femoral head

A

bone death d/t no blood supply

d/t trauma, diabetes, sickle cell SLE, RA, chronic corticosteroids, chronic EtOH

or idiopathic i.e. legg-calve-perthes disease

collapse of bone and destruction of hip joint d/t early asymptomatic i.e. not caught early

groin pain worse with weight-bearing

sx may mimic OA

usually needs total hip replacement

22
Q
A

avascular necrosis femoral head

23
Q

posterior hip dislocation

A

more common than anterior

developmental or traumatic

high-energy blunt force trauma e.g. MVA, car vs ped, falling from height

internal rotation and aDduction of hip often w/ sciatic nerve compression

24
Q
A

posterior hip dislocation

25
Q

proximal femur frx

A

femoral neck or intertrochanteric

falls, elderly, osteoporosis

hip or groin pain

complication: AVN d/t damage to circumflex femoral artery branches

26
Q
A

intertrochanteric femur frx

27
Q

legg-calve-perthes disease

defn and causes

A

idiopathic avascular necrosis of femoral head

typical blood supply (artery of the ligament to the head of the femur) is gradually replaced by medial and lateral circumflex femoral artery supply

this makes femur more prone to AVN

almost exclusively in white boys 3-12 y/o, median 7 years

usually no trauma hx

28
Q

legg-calve-perthes

clinical presentation and PE findings

A

insidious

mild hip or knee pain w/ limp, usually unilateral

if bilateral, not symmetric

decreased internal rotation and aBduction

3-12 y/o white boy

initial phase: normal radiographs

degenerative: flattened femoral head
regenerative: reossification of femoral head, but doesn’t fit right in acetabular cavity

29
Q
A

legg-calves-perthes

degenerative phase

30
Q

legg calve perthes

tx and prognosis

A

activity restriction or bedrest

casting, bracing, or surgical immobilization

kids remodel bone quickly, so early intervention usually allows femoral head to remold back into round shape

31
Q

sacroiliac joint dysfx

clinical presentation and PE findings

A

low back and buttocks pain, may radiate to anterior or posterior thigh

deep, aching

gradual

worse with any hip movement, walking, standing, weight-bearing

worse with palpation over SI ligaments or near posterior superior iliac spine

+FABER (flexion, aBduction, external rotation

radiology usually normal

32
Q

sacroiliac joint dysfx

tx and prognosis

A

NSAIDs

acute: ice
chronic: deep heat/ultrasound

glute and paraspinal strengthening

if refractory, injection with corticosteroid and/or proliferative agent + PT

usually self-limiting, esp if treated early

if tx delayed, can b//c chronic and debilitating

33
Q

hip OA

A

progressive cartilage degeneration

groin pain, but w/o tenderness to palpation in inguinal area

ranges from dull, aching, throbbing, to sharp, stabbing

worse with weight-bearing

possible limp

restricted ROM d/t structural changes and pain - internal rotation and aBduction

non-uniform joint space narrowing, bone cyst, bone sclerosis, osteophytes

34
Q

developmental hip dysplasia

A

aka congenital hip dislocation

poor fit b/w femoral head and acetabulum –> easy posterior subluxation

unilateral or bilateral

seems genetic, more in girls (80%)

newborn screening

pavlik harness = brace to prevent aDduction and hip extension

if treated in 1st few weeks good prognosis, otherwise juvenile OA likely

35
Q

slipped capital femoral epiphysis

A

physis = growth plate

normal: hip growth plate changes orientation during development to better bear weight

increased stress on joint + risk factor e.g. Down’s, obese, hypothyroid –> head of femur shifts through growth plate (frx)

sharp, severe pain in groin, may radiate to butt and knee

worse with movement or weight-bearing

leg is in external rotation, limp

decreased internal rotation and aBduction

xray

requires surgical pinning

36
Q

toxic synovitis of hip

A

idiopathic, transient synovitis

usually boys 3-7 y/o

acute pain, limp, sometimes inability to walk on affected limb most commonly in morning

generally not sick, CBC and ESR are normal

usually lasts 3-5 days

limited internal rotation of hip w/o pain on palpation

37
Q

trochanteric bursitis

A

inflammation of bursa between greater trochater and glute max insertion

IT band tightens and puts pressure, friction on bursa

usually acute, repetitive trauma e.g. running

gradual onset lateral hip

initially deep and aching, progresses to constant deep

when severe may be associated with pain down IT band and at lateral insertion site on knee

sometimes bruising or swelling over lateral hip

pain over trochanteric bursa and IT band on palpation

IT stretching reproduces pain

groin or knee pain on internal rotation would suggest OA or other pathology NOT bursitis

normal XR

38
Q

piriformis syndrome

A

local tenderness of piriformis with reproduction of sx on stretching or contraction of piriformis

39
Q

causes of lateral hip/thigh pain

A

trochanteric bursitis: pain on palpation, +/- IT pain and tightness

lateral femoral cutaneous nerve syndrome: neuropathic, no pain on palpation

40
Q

causes of groin pain in adults

A

OA: gradual, esp w/ old age

AVN: dx by MRI esp when risk factors present

41
Q

causes of groin pain in kids

A

developmental hip dysplasia: newborn/infant

toxic synovitis: transient, 3-5 days, boys 3-7

legg calves perthes: AVN in boys 3-12

slipped capital femoral ephisys: adolescent boys esp obese, hypothyroid, Down’s

42
Q

causes of buttocks pain

A

referred from lumbar disk ddd, radiculopathy, herniation

SI joint dysfunction: tenderness over ligaments

piriformis syndrome: piriformis spasm + sciatica

43
Q

lateral femoral cutaneous nerve syndrome

A

meralgia paresthetica

compression of lateral femoral cutaneous nerve as it courses deep to lateral edge of inguinal ligament

burning, numbness, parethesias down proximal-lateral thigh

no motor sx (this is a sensory nerve)

causes: tight belts, seat belt injury, obesity

SFM2 (11 decks)

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